Screening Adolescents for STIs/HIV: Key Partnerships Drive Innovative School-Based Program

State: FL Type: Promising Practice Year: 2017

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Duval County Health Department
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Screening Adolescents for STIs/HIV: Key Partnerships Drive Innovative School-Based Program
Duval County comprises close to 918 square miles located on the Northeastern coast of Florida. It has a population of approximately 913,010 residents. Duval County's population is 62% White, 30% Black, and 8% other races, with approximately 9% having Hispanic ethnicity (U.S. Census Bureau, 2015). Economic barriers to accessing health care exist in Duval County given that approximately 18% of residents live in poverty and 17% of residents are uninsured. Approximately 16% of Duval County's population is adolescent (between the ages of 13 to 24 years old). Sexually transmitted infections (STIs) and HIV are serious public health issues. STIs are common, especially among teens and young adults. There are about 20 million new cases of STIs in the United States each year, and close to half of these are in people between the ages of 15 to 24. Many young adults engage in sexual risk behaviors that can result in negative health outcomes, such as STI/HIV infection. According to the Youth Risk Behavior Survey (YRBS, 2015), 13% of middle school and 37% of high school students in Duval County have engaged in sexual activity, and many of these students report multiple lifetime sexual partners. Condom use among youth in Duval County is low, with 40% of high school students reporting unprotected sex during their last sexual encounter. The high level of sexual risk behaviors among Duval County youth are complicated by alarming rates of STI infection. For example, Duval County ranks 5th in the state of Florida for the highest rate of bacterial STI cases among young adults aged 15 to 19. Despite intervention efforts, Duval County (3,534.9/100,000) remains above the state rate (2,226.7/100,000) for the number of STI cases in this age group. Duval County (17.4/100,000) also remains above the state rate (12.1/100,000) for the number of new HIV infections among youth. The Teen Health Centers were initiated as a strategy to help realize the Florida Department of Health in Duval County's (DOH-Duval) strategic plan objective to reduce the rate of STIs among youth aged 15 to 24. To address the high rates of STI/HIV infection among Duval County youth, DOH-Duval, in collaboration with Duval County Public Schools, Jacksonville Area Sexual Minority Youth Network (JASMYN), and other key partners, established Teen Health Centers that provide key sexual health services in teen-friendly locations. There are currently five high schools participating in the project and three additional Teen Health Centers will open on high school campuses in the remaining years of the grant. JASMYN serves as an additional Teen Health Center location on this project. JASMYN is a community-based organization that operates a center for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth with comprehensive services including HIV prevention programs, support groups, and case management services. The location of the Teen Health Centers was determined through the use of Geographic Information Systems mapping of STI cases. This practice aims to bring comprehensive sexual health services to youth ages 13 to 19 years old in high-risk areas of Duval County. The Teen Health Center project is based on the successful evidence-based practice from Harlem, NY called the Gonorrhea Community Action Project. This program is funded by a grant from the Centers for Disease Control and Prevention (CDC) to Duval County Public Schools, and includes one full-time Health Support Technician, one half-time Disease Intervention Specialist, and one half-time Health Educator. Additional health educators and testing staff are provided by DOH-Duval's Disease Control Division. The success of this project relies heavily upon Duval County Public Schools and other community partners. These community partners include the Full Service Schools of Jacksonville, which provides space and aids in marketing, and JASMYN, which provides consulting and staff support for LGBTQ services and linkage. JASMYN serves as an additional Teen Health Center one day per week and brings key sexual health services to LGBTQ youth, a population at disproportionate risk for STI/HIV infection. By providing key sexual health services in teen friendly and accessible locations, our dynamic partnership has brought much needed health services to the youth of Duval County. The partners' combined efforts during school year 2015-2016 enabled 592 youth to access key sexual health services during 1,034 Teen Health Center visits. Teen Health Center staff provided 896 group education services, 298 HIV tests, 285 Gonorrhea/Chlamydia tests, and 62 pregnancy tests. Of those screened for STDs, HIV and/or pregnancy, 26 tested positive for Chlamydia, 1 tested positive for Gonorrhea, and 5 tested positive for pregnancy. Website: http://duval.floridahealth.gov/
Sexually transmitted infections (STIs) and HIV are serious public health issues. STIs are common, especially among young people. There are about 20 million new cases of STIs in the United States each year, and close to half of these are in people between the ages of 15 to 24. According to the Youth Risk Behavior Survey (YRBS, 2015), 13% of middle school and 37% of high school students in Duval County have engaged in sexual activity, and many of these students report multiple lifetime sexual partners. Condom use among youth in Duval County is low, with 40% of high school students reporting unprotected sex during their last sexual encounter. The high level of sexual risk behaviors among Duval County youth are complicated by alarming rates of STI infection. This project aims to reduce the rates of STI and HIV infection among youth in Duval County, Florida. Duval County ranks 5th in the state of Florida for the highest rate of bacterial STI cases among young adults aged 15 to 19. Despite intervention efforts, Duval County (3,534.9/100,000) remains above the state rate (2,226.7/100,000) for the number of STI cases in this age group. Duval County (17.4/100,000) also remains above the state rate (12.1/100,000) for the number of new HIV infections among youth. This project targets secondary school students enrolled in Duval County Public Schools. Duval County Public Schools serve approximately 62,000 middle and high school students in 48 schools. The student population at Duval County Public Schools is diverse: 61% of students are members of a racial/ethnic minority group, 3% report English as a second language, and 55% receive free or reduced lunch. Teens in low-income neighborhoods are less likely to have access to interventions that prevent unplanned pregnancies and STI/HIV transmission, such as sexual health education and teen sexual health services. The Teen Health Centers bring critical, developmentally appropriate, key sexual health services to teen-friendly and accessible locations. The Teen Health Centers were initiated as a strategy to help realize the Florida Department of Health in Duval County's (DOH-Duval) strategic plan objective to reduce the rate of STIs among youth aged 15 to 24. To address the high rates of STI/HIV infection among Duval County youth, DOH-Duval, in collaboration with Duval County Public Schools and other key partners, established six Teen Health Centers that provide key sexual health services in teen-friendly locations. The Teen Health Centers offer Duval County youth free sexual and reproductive health education, pregnancy testing, STI/HIV screening, STI/HIV treatment and linkage, community referrals, and a safe and reliable place to get accurate information. The Teen Health Centers provide these services in a convenient and accessible environment that is sensitive to the unique needs of youth, as well as to vulnerable populations facing significant barriers to access. There are currently five high schools participating in the project and three additional Teen Health Centers will open on high school campuses in the remaining years of the grant. JASMYN serves as an additional Teen Health Center location on this project. JASMYN is a community-based organization that operates a center for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth with comprehensive services including HIV prevention programs, support groups, case management services, and a teen-friendly health clinic that provides HIV/STI screening, treatment, and linkage services. The JASMYN Teen Health Center brings key sexual health services to a population that is at disproportionate risk for STI/HIV infection. Youth served during the outreaches are 13 to 19 year-olds. The location of the Teen Health Centers was determined through the use of Geographic Information Systems mapping of STI cases. Locations in close proximity to cluster centers were selected as Teen Health Center sites. The Teen Health Centers are based on a successful evidence-based practice from Harlem, NY called the Gonorrhea Community Action Project. The health education offered at the Teen Health Centers utilizes a peer health advocacy model and addresses knowledge about STIs, unintentional pregnancy, and the reduction of high-risk behavior that could put one at risk of acquiring STIs/HIV/unplanned pregnancies or fatherhood, including attitudes, beliefs, self-efficacy, and intention to seek care. One of the key differences between the Teen Health Centers and the Gonorrhea Community Action Project, is that the Teen Health Centers are located at teen-friendly and accessible locations, thereby reducing potential barriers to accessing key sexual health services. The Teen Health Centers are a timely response to help meet the Centers for Disease Control and Prevention (CDC) guidelines and recommendations for providing sexual health services for adolescents. These guidelines include gonorrhea and chlamydia screening, HIV testing, and the administration of the human papillomavirus (HPV) vaccine. The Teen Health Centers, can address many of the barriers that youth experience when accessing key sexual health services, such as atmospheres that are unappealing or locations that are not convenient. Delaying or avoiding health care can lead to an increased risk of transmitting STIs to others, as well as long-term negative consequences, including infertility, chronic pelvic pain, and cancer. Adolescents have been identified as a population in great need of improved access to health services. They have one of the lowest primary care use rates and the highest under- or un-insured rates in the United States. Delivering key sexual health services in environments that are teen-friendly and accessible is an essential part of a comprehensive approach to address the health needs of young people. When located on school campuses, these health centers are easily accessible and may be the first contact point for adolescents seeking health services. Additionally, the delivery of key sexual health services in easily accessible locations is an important strategy to increase access to health care for low-income and ethnically diverse adolescents who often experience inequities in access to care and health outcomes. Since the Teen Health Centers focus on adolescents, the providers are trained to work with and address their health needs and concerns about confidentiality. The success of the Teen Health Centers depends heavily upon collaboration between Duval County Public Schools, community partners, and DOH-Duval. This work is funded in part by a CDC grant awarded to Duval County Public Schools and includes one full-time Health Support Technician, one half-time Disease Intervention Specialist and one half-time Health Educator. Additional health educators and testing staff are provided by DOH-Duval's Disease Control Division. The design and implementation of the Teen Health Centers involved a number of important stakeholders including DOH-Duval Disease Control staff, Duval County Public Schools administration, and community partners. Cross-sector partnerships are essential to the successful implementation of health promotion activities targeted to youth. Our dynamic partnership allows for grant partners to pool resources, share expertise, and create new insights on better ways to address the health challenges facing our youth.
HIV in the U.S.|Teen Pregnancy
The Teen Health Centers aim to reduce the rates of sexually transmitted infection (STI) and HIV among youth in Duval County by providing key sexual health services to youth in teen-friendly and accessible locations. The primary objective of this practice is to increase access to key sexual health services, including education, STI/HIV/pregnancy screening, and linkage to treatment. To achieve this objective, the Department of Health in Duval County (DOH-Duval), in collaboration with Duval County Public Schools and other key partners, established six Teen Health Centers that provide key sexual health services to youth. The Teen Health Centers are outreach programs offered in teen-friendly and accessible locations that provide comprehensive health education, free condoms, STI/HIV/Pregnancy screening, STI treatment, community referrals, and a safe and reliable place to get accurate information. This practice addresses the unique challenges faced by youth accessing key sexual health services by providing these services in a convenient and accessible environment that is sensitive to the needs of youth. Coordinated effort among partners contributes to the success of the Teen Health Centers. The design and implementation of the Teen Health Centers involved a number of important stakeholders including DOH-Duval Disease Control staff, Duval County Public Schools administration, and community partners. These community partners include the Full Service Schools of Jacksonville, which provides space and aids marketing, and the Jacksonville Area Sexual Minority Youth Network (JASMYN), which provides consulting and staff support for LGBTQ services and serves as a Teen Health Center location. The Teen Health Center initiative has been underway since the fall of 2014. DOH-Duval plans to open a total of nine Teen Health Centers before current grant funding ends in 2017. The Teen Health Centers began in the 2014-2015 school year, with one site located in the Northside of Jacksonville. The following spring term, another center opened near downtown Jacksonville. The DOH-Duval has implemented an additional site each semester for a total of six sites as of fall 2016. Three additional Teen Health center locations will open on high school campuses before grant funding ends. JASMYN also serves as a Teen Health Center on this project. JASMYN is a community-based organization that operates a center for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth with comprehensive services including HIV prevention programs, support groups, and case management services. The location of the Teen Health Centers was determined through the use of Geographic Information Systems mapping of STI cases. Locations were selected in close proximity to cluster centers were selected as sites for the initial outreach implementation. The Teen Health Centers provide services to youth 13 to 19 year-olds, as well as to sexual partners that do not meet the age requirement. Our partnership has allowed for grant partners to pool resources, share expertise, and create new insights into better ways to address the health challenges facing our youth. Our partnership has implemented a number of strategies to facilitate collaboration among grant partners. For example, biweekly Teen Health Center meetings are held to discuss barriers and facilitators of success, strategies for implementation, and opportunities for improvement of services. In addition, weekly and monthly reports that summarize clinic activities and identify opportunities for improvement are shared with all partners. To ensure consistency in procedures across sites, a toolkit was created to document Teen Health Center procedures. Together these activities build the capacity of the Jacksonville Teen Health Centers, improve communication among key stakeholders, and streamline processes. This program is funded (in-part) by the Duval County Public Schools, and includes one full-time Health Support Technician, one half-time Disease Intervention Specialist, one half-time Health Educator, and a Prevention Coordinator. Additional health educators and testing staff are provided by DOH-Duval's Disease Control Division. The total budget for the 2015-2016 school year to operate the Teen Health Centers is approximately $75,000, with the majority of costs funded through the CDC grant. The space to operate the Teen Health Centers is offered in–kind from the Full Service Schools of Jacksonville and JASMYN. In addition, the Office of Performance Improvement receives approximately $20,000 to evaluate the Teen Health Centers. Sustainability funds are being secured from Duval County School to continue the Teen Health Center project after grant funding ends.
The Teen Health Centers are evaluated on an ongoing basis. To ensure the successful evaluation of the Teen Health Centers, the Office of Performance Improvement at the Florida Department of Health in Duval County (DOH-Duval), in collaboration with grant partners, developed an evaluation plan and logic model, designed data collection tools, oversaw data collection efforts, and analyzed customer satisfaction and clinic data. The Teen Health Center data is used to produce monthly and annual reports that summarize clinic activities. Evaluation of the Teen Health Centers focuses on four main areas: the demographics of youth accessing services at the Teen Health Centers, the number of services provided, positivity rates for pregnancy and STI/HIV screening, and customer satisfaction. Data to track the demographics of youth accessing services at the Teen Health Centers is collected using a patient intake form. The patient intake form was developed for this project and allows for the collection of data for grant reporting purposes. The patient intake form is completed when a student first arrives at the Teen Health Center to assess demographics (e.g., age, grade, sex, sexual orientation, home zip code) and is also used by Teen Health Center staff to track services provided during the appointment. For example, each intake form documents whether group education, Gonorrhea/Chlamydia screening, HIV testing, and pregnancy testing services were received. Test results and initiation of treatment are tracked through the electronic medical record system. Customer feedback is collected through the use of satisfaction surveys that are administered at the Teen Health Center appointment. To ensure consistency across sites, a toolkit containing Teen Health Center documents and procedures was created. The objective of the Teen Health Centers is to offer key sexual health services to Duval County youth in teen friendly settings. The partnerships combined efforts during school enabled 592 youth to access key sexual health services during 1,034 Teen Health Center visits. Youth receiving services at the Teen Health Centers were primarily between the ages of 15 to 19 years old (91%), male (60%), heterosexual (85%), and Black (76%). Close to 50% of youth receiving services resided in Health Zone 1 (urban core), an area of Duval County that has higher levels of poverty, lower level of educational attainment, and higher rates of many health conditions. Teen Health Center staff provided 896 group education services, 298 HIV tests, 285 Gonorrhea/Chlamydia tests, and 62 pregnancy tests. Of those screened for STDs, HIV and/or pregnancy, 26 tested positive for Chlamydia, 1 tested positive for Gonorrhea, and 5 tested positive for pregnancy. Youth that tested positive for an STI received treatment. Youth that tested positive for pregnancy were referred to appropriate community resources. Customer satisfaction surveys are distributed to youth attending the Teen Health Centers. During school year 2015-2016, over 80 youth attending the Teen Health Centers completed a customer satisfaction survey. Of those completing a customer satisfaction survey, 98% indicated that they were either satisfied or very satisfied with their experience. In addition, 96% reported that they would refer a friend to the Teen Health Centers. During school year 2015-2016, many youth returned to the Teen Health Centers for multiple visits. Reasons students returned to the Teen Health Centers included to receive additional testing and education. Here are some quotes from students attending the Teen Health Centers: Y'all are great” I keep coming back to the Teen Health Center because I get some new information each time” Ms. Samantha (Health Educator) is very helpful and caring” Our partnership has implemented a number of strategies to facilitate collaboration among grant partners and to continuously improve our work. For example, biweekly Teen Health Center meetings are held to discuss barriers and facilitators of success, strategies for implementation, and opportunities for improvement of services. In addition, weekly and monthly reports that summarize clinic activities and identify opportunities for improvement are shared with all partners. Together these activities build the capacity of the Jacksonville Teen Health Centers, improve communication among key stakeholders, streamline processes, and allow for sharing of our successes.
One of the most important lessons learned during the implementation of the Teen Health Centers is the need to improve communication among the Teen Health Center locations and key stakeholders. Our partnership implemented a number of strategies to facilitate effective communication among key stakeholders. For example, biweekly Teen Health Center meetings are held to discuss barriers and facilitators of success, strategies for implementation, and opportunities for improvement of services. In addition, weekly and monthly reports that summarize clinic activities and identify opportunities for improvement are shared with all partners. To ensure consistency in procedures across sites, a toolkit was created documenting Teen Health Center procedures. Together these activities build the capacity of the Teen Health Centers, improve communication among key stakeholders, and streamline processes. Another significant barrier encountered has been related to reaching more youth at the Teen Health Centers. Initially, challenges were encountered related to the effective marketing of Teen Health Center services through Duval County Public Schools (DCPS) personnel. These barriers have been largely resolved as more teachers and school staff become aware and supportive of the program. In addition, a more widespread approach has been adopted to ensure that youth are aware of the Teen Health Centers and the services that are offered. Initially, the project relied on teachers and other school personnel, such as school health nurses, to refer students to the Teen Health Centers. Teen Health Center staff also actively distributed flyers to students. In addition to these ongoing efforts, school announcements are now made on days where Teen Health Centers are open. These brief announcements occur at the school where Teen Health Centers are located, and notify students of the availability of free group education and STI/HIV/pregnancy screening services. Although the Teen Health Centers aim to increase access to key sexual health services, many Duval County youth may continue to experience significant challenges accessing these important health services. For example, students may be unable to attend the Teen Health Centers after school if they rely on school buses to get home. To help minimize this potential barrier, bus tickets are now offered to students. In addition, our partnership is exploring ways to offer key sexual health services during the school day. During school year 2016-2017, the Florida Department of Health in Duval County (DOH-Duval), in collaboration with Duval County Public Schools, will implement an in-school STI/HIV screening program to educate students about STIs/HIV, and identify and treat chlamydia and gonorrhea among Duval County middle and high school students. During in-school testing days, students will attend a group education program on STIs/HIV, including risk factors and prevention methods. Each student that attends the group education session will be offered confidential, urine-based testing. Students that test positive will be provided treatment and offered appropriate referrals. By providing STI/HIV testing and treatment during the school day, many of the known barriers adolescents encounter when seeking appropriate health care will be reduced. The Teen Health Centers have increased access to key sexual health services among youth in Duval County. DOH-Duval plans to continue implementation of the Teen Health Centers after grant funding ends. There is significant stakeholder interest and commitment to sustaining the Teen Health Centers. Our plan for sustainability includes developing budgetary support from DCPS and continued in-kind support from DOH-Duval. In addition, future grants will be pursued to fund the group education and STI/HIV/pregnancy screening services offered at the Teen Health Centers. For the 2016-2017 school year, DOH-Duval received an additional $80,000 in sustainability funds from DCPS. In addition, Full Service Schools of Jacksonville and JASMYN have indicated willingness to continue offering space for the operation of the Teen Health Centers. Furthermore, as the project expands, the partnership is exploring variations on the current model, including mass screenings during the school day and the possible utilization of a mobile unit.
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